Client and healthcare worker experiences with differentiated HIV treatment models in Eswatini

Introduction Universal access to antiretroviral therapy (ART) is a cornerstone of Eswatini’s national HIV strategy, and the number of people on ART in the country more than tripled between 2010 and 2019. Building on these achievements, the Ministry of Health (MOH) is scaling up differentiated service delivery, including less-intensive differentiated ART (DART) models for people doing well on treatment. We conducted a mixed-methods study to explore client and health care worker (HCW) perceptions of DART in Eswatini. Methods The study included structured site assessments at 39 purposively selected health facilities (HF), key informant interviews with 20 HCW, a provider satisfaction survey with 172 HCW and a client satisfaction survey with 270 adults. Results All clients had been on ART for more than a year; 69% were on ART for ≥ 5 years. The most common DART models were Fast-Track (44%), Outreach (26%) and Community ART Groups (20%). HCW and clients appreciated DART, noting that the models often decrease provider workload and client wait time. Clients also reported that DART models helped them to adhere to ART, 96% said they were “very satisfied” with their current model, and 90% said they would recommend their model to others, highlighting convenience, efficiency and cost savings. The majority of HCW (52%) noted that implementation of DART reduced their workload, although some models, such as Outreach, were more labor-intensive. Each model had advantages and disadvantages; for example, clients concerned about stigma and inadvertent disclosure of HIV status were less interested in group models. Conclusions Clients in DART models were very satisfied with their care. HCW were also supportive of the new approach to HIV treatment delivery, noting its advantages to HF, HCW and to clients. Given the heterogeneous needs of people living with HIV, no single DART model will suit every client; a diverse portfolio of DART models is likely the best strategy.

mixed-methods study to explore client and HCW perceptions of Eswatini's differentiated ART models.

Study setting
The study took place between August 2019 and October 2019 at 39 of Eswatini's 187 health facilities providing ART and their community catchment areas. Health facilities were purposively selected; selection criteria included facility region, health facility type (hospital, health center, clinic), and provision of differentiated ART services.

Study design
The cross-sectional mixed methods study was designed to explore client and HCW experiences with DSD in general and with specific differentiated ART models, to identify barriers and facilitators of differentiated ART scale-up, and to provide rapid policy-relevant information to MOH (see study protocol in S1 Appendix). Study tools included: (a) a site survey to describe differentiated ART implementation at each health facility; (b) satisfaction surveys with adult clients enrolled in differentiated ART; (c) satisfaction surveys with HCW providing differentiated ART; and (d) key informant interviews with HCW.

Sampling, data collection and data management
Site survey: A senior HCW at each participating health facility was recruited to complete a selfadministered paper-based survey capturing relevant facility-level characteristics. The 13-question survey assessed information about staffing, number and volume of clients on ART, available models, and number of clients enrolled in each model and included open-ended questions about future differentiated ART implementation plans and perceived barriers to scale-up. Responses from paper surveys were entered and uploaded by study staff into tablets using a cloud based SurveyCTO (Dobility, Inc., Cambridge, MA, USA) database platform for data management and analysis.
Client satisfaction surveys. We enrolled a purposively selected sample of adults aged 18 and older enrolled in differentiated ART at the study sites and presenting for care during the study period, aiming to include at least one client from each model offered by the health facility. Trained study staff administered the client satisfaction questionnaire in siSwati or English and recorded client responses into a tablet computer using SurveyCTO; the questionnaire included 42-60 questions, depending on the differentiated ART model of the participant, and took approximately 20-30 minutes.
HCW satisfaction surveys. A purposive sample of at least six HCW from each health facility participated in the HCW satisfaction survey, which included 34 closed-ended questions and 12 open-ended questions. The survey was self-administered in English using paper-based forms and took approximately 20-30 minutes to complete. Data from paper surveys were entered by study staff into a tablet computer using SurveyCTO.
HCW key informant interviews. We conducted key informant interviews with 20 purposively selected HCW, all of whom had experience implementing differentiated ART. We intentionally included a variety of HCW cadres to provide perspectives on multiple aspects of differentiated ART within a facility including client consultations, refills and pharmacy operations. Key informant interviews were conducted in siSwati or English using an interview guide and took approximately 20-30 minutes. Interviews were audio recorded and transcribed for analysis.

Data analysis
Quantitative data from site, client and HCW surveys were exported from Survey CTO, and descriptive statistics including frequencies and percentages were compiled using Stata version 12 (StataCorp LP, College Station, TX, USA). Comparisons of client satisfaction levels across models were done in R [25] using Fisher's exact test with p-values computed via Monte Carlo simulation (n = 100,000 simulations). Qualitative data from key informant interviews were analyzed using standard thematic analyses, identifying repeated ideas, themes, and thematic narratives through coding and synthesis at increasingly higher levels of abstraction using Dedoose (SocioCultural Research Consultants, LLC, Los Angeles, CA, USA).

Ethics reviews
The Eswatini National Health Research Review Board (SHR 150/2019) and the Columbia University Medical Center Institutional Review Board (IRB-AAAS6058) approved the protocol. Survey participants provided verbal informed consent and key informant interview participants provided written informed consent.

DART impact on health facility volume, HCW workload and client time
HCW had diverse perspectives on the impact of differentiated ART models on health facility volume. In the HCW survey, 90 (52%) said volume decreased, 38 (22%) said there was no impact, 25 (15%) said volume increased, and 19 (11%) did not respond.
"What I've noted about Fast-Track is it has decreased the number of clients-our patient queues and the waiting time has been reduced a bit as clients on Fast-Track have to only produce their sheets, they don't have to wait much."-Senior Nurse, Key informant interview participant The majority of HCW reported that differentiated ART implementation had an impact on their workload: 110 (64%) said it decreased, 30 (17%) said it increased, 27 (16%) noted no change and 5 (3%) did not respond. Those describing increased workload pointed to specific models, such as Outreach, compared to models requiring less HCW time, such as Fast-Track.
The DSD model has made it easier to adhere to my ARV regimen" "Being in this DSD model has helped to make it easier to manage living with HIV" "I would recommend this service to others living with HIV" � Fisher's exact test p-value.

Discussion
Overall, clients were very satisfied with the differentiated ART models they had opted to join and felt that differentiated ART made it easier to adhere to treatment. Overall, 90% of clients said they would recommend differentiated ART to others living with HIV, highlighting convenience, efficiency, and cost savings. These findings are consistent with studies of client preferences for characteristics of differentiated ART models in urban Zimbabwe, where less frequent visits and shorter wait times were prioritized [26]. They are also consistent with studies in Zambia, Malawi and South Africa which found strong client preferences for multi-month dispensing [23,24,27], and with a systematic review of 11 studies of client preferences for HIV service features, which also noted the importance of less-frequent drug pickups and shorter waiting times [28]. Studies of group models, including community-and facility-based adherence clubs in South Africa [29,30] highlight client preferences for convenience, social support and solidarity. Importantly, many studies find substantial heterogeneity in client preferences, reinforcing the need for diverse differentiated ART models. For example, concerns about inadvertent disclosure in group models make them less attractive to clients concerned about stigma and discrimination, highlighting the importance of stigma reduction training for HCW and thoughtful spatial organization of health facilities to maximize visual and auditory privacy and avoid unintentional disclosure of HIV status [31,32]. Differentiated ART can also be tailored to meet the needs and expectations of specific groups, including key populations [33,34], people with advanced HIV disease [35], pregnant and breastfeeding women [36,37], adolescents and youth [12,38], and migrant/mobile populations [39]. In addition, the importance of kind, person-centered care often outweighs client preferences for convenience and cost-savings [16,26,28].
HCW were also satisfied with differentiated ART implementation, with 64% noting a decreased workload and 52% reporting that health facilities were less congested with shorter wait times following the launch of differentiated ART. This is consistent with surveys of HCW in Malawi [22] and Zambia [24] which found HCW to be supportive of multi-month dispensing; fewer data are available regarding HCW perceptions of other differentiated ART models. As with clients, HCW perceptions varied by differentiated ART model, with Fast-Track decreasing provider workloads and Outreach increasing them.
Limitations of this study include its non-random sampling of facilities and individuals, which reduces the generalizability of findings. Facilities were selected to include a range of facility types and settings across all four regions; however, since this did not involve a randomized process for selection, findings may not be representative of all health facilities or health providers providing differentiated ART in Eswatini. The sampling may have predisposed to clients who were more satisfied with differentiated ART by surveying current differentiated ART clients retained in care, and because clients who were more satisfied with their care may have disproportionately agreed to participate. Key informant interview responses may also be subject to social desirability bias or courtesy bias, as HCW were reporting their perceptions of services provided and endorsed by MOH. Despite these limitations, we believe that the sample size, mixed methods, and inclusion of both HCW and clients resulted in policy-relevant findings and provide a foundation for further implementation science research.

Conclusions
Clients who chose to be in differentiated ART models were very satisfied with their care. HCW were also supportive of the new approach to HIV treatment delivery, noting its advantages to health facilities, HCW and to clients. Given the heterogeneous needs and preferences of people living with HIV, no single model will work for every client; a diverse portfolio of differentiated ART models for diverse groups is likely the best strategy.